Lessons learned from 118,970 multidetector computed tomographic intravenous contrast material administrations: impact of catheter dwell time and gauge, catheter location, rate of contrast material administration, and patient age and sex on volume of extravasate

Intravenous contrast medium extravasation: systematic review and updated ESUR Contrast Media Safety Committee Guidelines

NEED FOR A REVIEW

Guidelines for management and prevention of contrast media extravasation have not been updated recently. In view of emerging research and changing working practices, this review aims to inform update on the current guidelines.

AREAS COVERED

In this paper, we review the literature pertaining to the pathophysiology, diagnosis, risk factors and treatments of contrast media extravasation. A suggested protocol and guidelines are recommended based upon the available literature.

KEY POINTS

• Risk of extravasation is dependent on scanning technique and patient risk factors. • Diagnosis is mostly clinical, and outcomes are mostly favourable. • Referral to surgery should be based on clinical severity rather than extravasated volume.

Extravasation of iodinated contrast medium in cancer patients undergoing computed tomography

Objective

The aim of this study was to evaluate the incidence of extravasation of iodinated contrast medium (ICM) at the site of intravenous injection in oncology patients submitted to computed tomography (CT).

Materials and Methods

This was a retrospective, descriptive, single-center study that evaluated all patients who underwent CT with ICM administration and presented ICM extravasation, at a cancer center, between January 2010 and December 2015.

Results

During the study period, we evaluated a total of 99,076 ICM injections and identified 199 cases of extravasation, the incidence rate therefore being 0.20%. Among the patients who presented extravasation, the mean age was 59.22 years and 60% were female. The extravasation was classified as mild in 94.10% of the patients and as moderate in 5.90%. There were no cases of severe extravasation in the sample.

Conclusion

The incidence of ICM extravasation in cancer patients submitted to CT in the present study was similar to that reported for the general population, according to other studies in the literature. The vast majority of cases of extravasation were considered mild, and no severe cases were observed in the study sample.

MRI and CT contrast media extravasation: A systematic review

BACKGROUND

This systematic review combines data from multiple papers on contrast media extravasation to identify factors contributing to increased extravasation risk.

METHODS

Data were extracted from 17 papers reporting 2191 extravasations in 1,104,872 patients (0.2%) undergoing computed tomography (CT) or magnetic resonance imaging (MRI).

RESULTS

Extravasation rates were 0.045% for gadolinium-based contrast agents (GBCA) and nearly 6-fold higher, 0.26% for iodinated contrast agents. Factors associated with increased contrast media extravasations included: older age, female gender, using an existing intravenous (IV) instead of placing a new IV in radiology, in-patient status, use of automated power injection, high injection rates, catheter location, and failing to warm up the more viscous contrast media to body temperature.

CONCLUSION

Contrast media extravasation is infrequent but nearly 6 times less frequent with GBCA for MRI compared with iodinated contrast used in CT.

Contrast media extravasations in patients undergoing computerized tomography scanning: a systematic review and meta-analysis of risk factors and interventions

OBJECTIVE

To identify risk factors and interventions preventing or reducing contrast medium extravasation.

INTRODUCTION

Computed tomography (CT) is a radiological examination essential for the diagnosis and monitoring of many diseases. It is often performed with the intravenous (IV) injection of contrast agents. Use of these products can result in a significant complication, extravasation, which is the accidental leakage of IV material into the surrounding tissue. Patients may feel a sharp pain and skin ulceration or necrosis may develop.

INCLUSION CRITERIA

This review considered studies that included patients (adults and children) undergoing a CT with IV administration of contrast media. The risk factors considered were patient demographics, comorbidities and medication history. This review also investigated any strategies related to: contrast agent, injection per se, material used for injection, apparatus used, healthcare professionals involved, and patient risk assessment performed by the radiology personnel. The comparators were other interventions or usual care. This review investigated randomized controlled trials and non-randomized controlled trials. When neither of these were available, other study designs, such as prospective and retrospective cohort studies, case-control studies and case series, were considered for inclusion. Primary outcomes considered were: extravasation frequency, volume, severity and complications.

METHODS

The databases PubMed, CINAHL, Embase, the Cochrane Register of Controlled Trials, Web of Science PsycINFO, ProQuest Dissertations and Theses A&I, TRIP Database and ClinicalTrials.gov were searched to find both published and unpublished studies from 1980 to September 2016. Papers were assessed by two independent reviewers for methodological validity using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Data were extracted using the standardized data extraction tool from JBI SUMARI. In one case, quantitative data from two cohort studies were pooled in a statistical meta-analysis. However, generally, statistical pooling was not possible due to heterogeneity of the interventions, populations of interest or outcomes. Accordingly, the findings have been presented in narrative form.

RESULTS

Fifteen articles were selected from a total of 2151 unique studies identified. Two were randomized controlled trials and 13 were quasi-experimental and observational studies. The quality of these studies was judged to be low to moderate. Some patient characteristics, such as female sex and inpatient status, appeared to be risk factors for extravasation. Additionally, injection rate, venous access site and catheter dwelling time could affect the volume extravasated. Preliminary studies seemed to indicate the potential of extravasation detection accessories to identify extravasation and reduce the volume extravasated. The other interventions either did not result in significant reduction in the frequency/volume of extravasation, or the results were mixed across the studies.

CONCLUSIONS

The majority of the studies included in this review evaluated the outcomes of extravasation frequency and volume. Given the quality of the primary studies, this systematic review identified only potential risk factors and interventions. It further highlighted the research gap in this area and the importance of conducting trials with solid methodological designs.

The effect of four-phasic versus three-phasic contrast media injection protocols on extravasation rate in coronary CT angiography: a randomized controlled trial

Objectives

Contrast media (CM) extravasation is a well-known complication of CT angiography (CTA). Our prospective randomized control study aimed to assess whether a four-phasic CM administration protocol reduces the risk of extravasation compared to the routinely used three-phasic protocol in coronary CTA.

Methods

Patients referred to coronary CTA due to suspected coronary artery disease were included in the study. All patients received 400 mg/ml iomeprol CM injected with dual-syringe automated injector. Patients were randomized into a three-phasic injection-protocol group, with a CM bolus of 85 ml followed by 40 ml of 75%:25% saline/CM mixture and 30 ml saline chaser bolus; and a four-phasic injection-protocol group, with a saline pacer bolus of 10 ml injected at a lower flow rate before the three-phasic protocol.

Results

2,445 consecutive patients were enrolled (mean age 60.6 ± 12.1 years; females 43.6%). Overall rate of extravasation was 0.9% (23/2,445): 1.4% (17/1,229) in the three-phasic group and 0.5% (6/1,216) in the four-phasic group (p = 0.034).

Conclusions

Four-phasic CM administration protocol is easy to implement in the clinical routine at no extra cost. The extravasation rate is reduced by 65% with the application of the four-phasic protocol compared to the three-phasic protocol in coronary CTA.

Key Points

• Four-phasic CM injection-protocol reduces extravasation rate by 65% compared to three-phasic.

• The saline pacer bolus substantially reduces the risk of CM extravasation.

• The implementation of four-phasic injection-protocol is at no cost.

[Extravasation of contrast media at the puncture site: Strategies for managment]

The incidence of contrast medium extravasation at the venipuncture site has increased with the generalized use of automatic injectors. Most extravasations only cause slight edema and erythema. Nevertheless, in some cases extravasation can result in severe skin lesions or even in compartment syndrome. Lesions caused by extravasation usually resolve spontaneously with conservative treatment. Although the complications of extravasation are well known, institutional protocols are normally lacking and the criteria for taking action and the type of treatment, whether based on the literature or personal preferences, tend to vary. In this article, we review the incidence, risk factors, clinical manifestations, and options for preventing and treating contrast medium extravasation in soft tissues. Finally, we present the protocol we use to manage extravasation at our hospital.